Request for Textbooks in an Alternate Format

For use only by students authorized by Services for Students with Disabilities for alternate format textbooks.

General Information

Last Name	First Name	B-Number

Email Address	Local Phone Number

Textbook Information

Title of Textbook

Edition Number & Copyright Year

Author(s)

Name of Course

Textbook ISBN

Name of Professor

Name of Book Publisher(s)

Book Needed By this Date

Textbook Format PDF WORD KESI

Additional Comments

Did you check to see if the book is already available in an alternate format at websites such as www.learningally.org, www.bookshare.org, www.worldcat.org, and www.gutenberg.org?

Did you try to "look inside" the book at a bookstore or at websites such as Amazon or Google Books to make sure you need the book in an alternate format?

Accessibility Details

AGREEMENT ON THE USE OF RECORDED, ELECTRONIC OR OTHER ALTERNATIVELY FORMATTED COURSE MATERIALS

· I agree that I am enrolled for the semester and the particular course(s) for which I am requesting alternatively formatted instructional materials.

· I have provided the designated college official with appropriate documentation of the disability that prevents me from using standard instructional material. I understand that this documentation will be kept on file at the college.

· I understand that I must purchase instructional materials at the same cost as other students.

· I agree that  I will not copy or reproduce alternatively formatted instructional materials nor allow anyone else to do so pursuant to the requirements of the copyright revision act of 1976 as amended (17 U.S.C.  §101 et seq.).

· I will not share alternatively formatted materials with any other party.

· I understand that any violation of this agreement may be considered a violation of the college's Student Code of Conduct and may result in penalties including suspension and expulsion.  Violations may also constitute a violation of federal and/or state laws and may result in civil or criminal prosecution, payment of fines or other moneys to the copyright holder, and/or incarceration. 

Before receipt of materials, this agreement shall be signed by the student and the designated college official and kept on file each semester in which the student requests alternatively formatted materials.

By typing your full name in the box below and submitting this request, you indicate that you have read and understand the policies outlined above and agree and comply with them.

E-signature: